Provider Demographics
NPI:1285727859
Name:REYNOLDS, SHANE E (PA-C)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:E
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9609
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9609
Mailing Address - Country:US
Mailing Address - Phone:623-773-2273
Mailing Address - Fax:623-773-2274
Practice Address - Street 1:7615 W THUNDERBIRD RD
Practice Address - Street 2:STE 106
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6083
Practice Address - Country:US
Practice Address - Phone:623-773-2273
Practice Address - Fax:623-773-2274
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173336Medicaid